FOCUS
Cite as: M. Bosmann, Sci. Immunol.
CORONAVIRUS
Complement control for COVID-19
Markus Bosmann1,2,3,4*
1
Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, 02118, MA, USA. 2Center for Thrombosis and Hemostasis, University Medical
Center Mainz, 55131 Mainz, Germany. 3Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, 02118, USA. 4Research Center
for Immunotherapy (FZI), University Medical Center Mainz, 55131 Mainz, Germany.
*Corresponding author. Email: mbosmann@bu.edu
Excessive complement activation contributes to lung disease and adverse patient outcomes in COVID-19
(see the related Research Articles by Yan et al. and Ma et al.).
The complement system is an integral part of innate immune
defense. It consists of about 50 proteins in plasma, on cell
surfaces and inside host cells. The traditional view is that
complement proteins guard the local extracellular spaces and
systemic bloodstream against invading pathogens. Loss-of-
function mutations resulting in terminal complement
pathway deficiencies are associated with a 10,000-fold higher
risk for life-threatening meningococcal infections in humans.
Surprisingly, the complement system is redundant for
defense against most pathogens except encapsulated
bacteria. Newer concepts embrace the view that complement
factors mediate functions inside cells either directly or
through surface receptors. Complement activity fine-tunes
homeostasis, metabolism and biogenesis. On the other hand,
uncontrolled complement activation causes disease and can
even worsen the outcome of infections. Toxic complement
effectors mediate tissue destruction and organ injury during
inflammatory diseases. Acute respiratory distress syndrome
(ARDS) and sepsis are frequent and severe complications of
acute infections and notorious for excessive complement
consumption. The three pathways of complement activation
are designed for immune sensing of non-self surfaces and
foreign antigens. The mannose-binding lectin (MBL)/ficolin
pathway starts with soluble pathogen pattern recognition
receptors as sensors for foreign carbohydrate motifs (Fig. 1).
The alternative pathway is fueled by a spontaneous
‘smoldering’ hydrolysis of C3 targeting all surfaces, unless
these surfaces present complement inhibitory proteins
(CD46, CD55, CD59) as a protective self-signal. This C3 ‘tick-
over’ is sustained by the high concentrations of C3 in plasma
(1-2 g/L) – the highest level of all complement factors. The
classical pathway is initiated by antigen-antibody complexes
which are recognized by the multimeric C1 complex. As a
safeguard, IgG antibodies bound in clusters or pentameric
IgM are required to surpass the activation threshold. All
complement pathways converge on C3 convertase complexes
leading to C3 cleavage into the larger C3b and the smaller
anaphylactic C3a peptides. C3b is essential for the formation
of C5 convertase for cleavage of C5 into C5b and the
First release: 25 May 2021
10.1126/sciimmunol.abj1014 (2021).
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anaphylatoxin C5a. C5b is the starting point of the pore-
forming membrane attack complex (MAC) consisting of C5b-
C9 with a channel diameter of ~100 Å. The C3/C5 hub
represents a gigantic amplification loop. The alternative
C3bBb convertase (half-life ~3 min) cleaves additional C3,
resulting in more C3bBb and so on and so forth. This
enzymatic chain reaction can deposit millions of C3b
molecules on target surfaces in a few seconds. It is no surprise
that such explosive events need to be tightly regulated to
maintain the delicate balance of effective and justified
pathogen attack, while avoiding damage of innocent
bystander cells.
In the April and May issues of Science Immunology, two
articles highlight the importance of complement activation
in severe COVID-19. Ma et al. report an observational clinical
study of a total of n=259 participants classified in subcohorts
of critically ill SARS-CoV-2 patients (from two clinical cen-
ters) compared to patients with influenza or acute respiratory
failure of other causes requiring invasive mechanical ventila-
tion (1). Higher complement activation products in blood cor-
related with and predicted increased disease severity. The
concentrations of soluble MAC (sC5b-C9) were higher
(p<0.0001) in COVID-19 patients as compared to influenza
patients. SARS-CoV-2-associated acute respiratory failure
showed increased sC5b-C9 compared to ARDS from non-
COVID-19 etiologies. The plasma levels of sC5b-C9 and C5a
correlated as expected, since both analytes arise together
from C5 cleavage, although C5a has an ultra-short plasma
half-life (<5 min). C5a is rapidly inactivated by plasma car-
boxypeptidase N and B, which remove the C-terminal argi-
nine residue from the polypeptide chain. The degradation
product C5adesArg has low affinity for the C5aR1 receptor but
retains binding to the homologous C5aR2 receptor. Comple-
ment diagnostics remains a technically challenging field, and
not just because of the volatile nature of activation products.
Antibody-based tests must selectively recognize the ne-
oepitopes of complement proteins which are created by pro-
teolytic cleavage. Cross-reactivity of anti-C5a antibodies with
C5 or C5b can be a serious impediment.
immunology.sciencemag.org (Page numbers not final at time of first release) 1
 Ma et al. also addressed which of the three complement
activation pathways is engaged (1). The authors found higher
concentrations of Factor B and Ba in severe COVID-19 pa-
tients who required intensive care treatment and in non-sur-
vivors. Factor B is a zymogen in the alternative pathway.
SARS-CoV-2 infection down-regulates expression of CD46,
CD55 and CD59 (2), which may contribute to increased alter-
native pathway activation. It is worth mentioning that the
C3bBb amplification loop is also triggered by the MBL/ficolin
and classical pathways. The SARS-CoV-2 S-protein contains
numerous N-acetylglucosamine moieties (3). N-acetylglu-
cosamine is recognized by ficolins. SARS-CoV-2 N-protein is
likewise glycosylated and directly binds to MASP2 of the
MBL/ficolin pathway. The classical pathway may be activated
in the later phases of infection by virus-specific antibodies
(Fig. 1) and COVID-19-associated autoantibodies. The latter
could fuel tissue injury. Lastly, Ma et al. describe the statisti-
cal correlation of Factor D (which cleaves Factor B in the al-
ternative pathway) with markers of endothelial cell injury
(Ang2) and coagulation such as von Willebrand Factor (vWF)
which is released by activated platelets and endothelial cells
(1). The cross-talk between coagulation and complement
could contribute to COVID-19-associated coagulopathy and
thromboembolic events. Thrombin can directly cleave C5 to
bypass C3 (4). C5a ligation with C5aR1 and C5aR2 induces
extracellular trap formation and appearance of externalized
histones (5), which are procoagulant and provoke lung injury.
In the second article, Yan et al. identify that the tran-
scriptomic signatures of SARS-CoV-2 infected human lung
epithelial cells were enriched for changes in complement
gene expression (6). SARS-CoV-2 induced Factor B and C3 as
the central players of the alternative pathway, but also up-
regulated other complement genes such as C1r and C1s. The
expression levels of C3 correlated with viral loads. In scRNA-
Seq data sets from biopsies and lavages of COVID-19 patients,
C3 was up-regulated in type II alveolar epithelial cells (AT2s)
and the C3aR receptor was induced in macrophages and
monocytes. It is appreciated that extrahepatic production of
complement factors occurs at proximal sites of pathogen en-
counters such as in organs with mucosal surfaces and in leu-
kocytes. However, not all lung cell types produce complement
factors and no single cell type expresses all complement
genes in relevant quantities. Yan et al. found that C3 protein
was processed to its active form in SARS-CoV-2 infected lung
epithelial cells (Calu-3 and iPSC-derived AT2s). C3a was de-
tected in the lung epithelial cells and existed in direct linear
correlation with SARS-CoV-2 N-protein. The C3 activation
was prevented by a cell-permeable Factor B inhibitor. The au-
thors interpret their findings in support of the concept of a
non-traditional intracellular complement activation mecha-
nism. Cathepsin L can process C3 into biologically active C3a
and C3b (7). Interestingly, Cathepsin L expression is
First release: 25 May 2021 immunology.sciencemag.org
increased by SARS-CoV-2 pseudovirus infection, primes S-
protein and enhances virus entry (8). In addition, invading
pathogens can carry bound C3 into the cytosol (9). The intra-
cellular C3 flags viruses for proteasomal degradation and
contributes to the activation of the viral RNA-sensing MAVS
signaling pathway (9). Interestingly, several viruses have
evolved evasion strategies to cleave C3 with viral proteases
(9).
Yan et al. further characterize that SARS-CoV-2-induced
expression of C3 and Factor B was dependent on type I inter-
ferons, the interferon-activated JAK1/2-STAT1 signaling
pathway and NF-κB RelA (6). The JAK1/2 inhibitor rux-
olitinib reduced generation of C3a, presumably by shutting
Downloaded from http://immunology.sciencemag.org/ by guest on May 26, 2021
off C3 and Factor B production during SARS-CoV-2 infection.
In conclusion, complement activation is a predominant
feature of severe COVID-19. Several approaches are conceiv-
able to control complement activation as a therapeutic prin-
ciple in COVID-19 (9). A number of complement blockers are
either readily available for drug repurposing or in advanced
stages of drug development (Fig. 1). Eculizumab is a mono-
clonal antibody to block C5 conversion and the first drug of
its class. Eculizumab improves the life expectancy of patients
with paroxysmal nocturnal hemoglobinuria (an acquired de-
ficiency in glycosylphosphatidylinositol-anchored CD55 and
CD59) and is effective in treating atypical hemolytic uremic
syndrome (aHUS) and neuromyelitis optica spectrum disor-
der (NMOSD). C3 inhibition can be achieved by AMY-101 and
pegcetacoplan. It is too early to predict which complement
blocker may have the best efficacy and a favorable risk profile
to selectively suppress hyperinflammation while sparing the
protective antiviral activities of complement. Clinical trials to
control complement activation and improve patient out-
comes of COVID-19 are underway.
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Acknowledgments: The author thanks Catherine O’Neal for reading the manuscript,
Archana Jayaraman for assistance and the Evans Center for Interdisciplinary
Biomedical Research at Boston University School of Medicine for their support of
the Affinity Research Collaborative on ‘Respiratory Viruses: A Focus on COVID-
19’. Funding: The author’s research is supported by the National Institutes of
Health (1R01HL141513, 1R01HL139641, 1R01AI153613, 1UL1TR001430) and the
Deutsche Forschungsgemeinschaft (BO3482/3-3). Competing Interests: The
author declares no competing interests.

Published First Release 25 May 2021

10.1126/sciimmunol.abj1014

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Fig. 1. Current concepts of complement activation and potential therapeutic interventions in severe COVID-19.
SARS-CoV-2 infection of alveolar epithelial cells (type II and type I) and subsequent interferon-dependent JAK1/2-
STAT1–induced expression of C3 and Factor B culminates in nontraditional intracellular processing of complement
proteins. In the extracellular spaces, SARS-CoV-2 activates complement via the mannose-binding lectin (MBL)/ficolin
pathway which senses glycosylated S- and N-proteins. The C3 ‘tick-over’ of the alternative pathway is accelerated by
a lack of complement inhibitors (CD46, CD55, CD59) on infected host cells and virions. The classical pathway is
activated by antibodies against viral antigens and COVID-19–associated autoantibodies. All complement activation
mechanisms converge on the C3/C5 hub to form the membrane-attack complex (MAC, C5b-C9) and generate
anaphylatoxins (C3a, C5a). These effectors recruit myeloid cells and cause endothelial activation, endothelial injury,
coagulopathy and hyperinflammation. The figure shows the molecular targets of several complement-inhibiting drugs
proposed as COVID-19 treatments: eculizumab and ravulizumab block C5 conversion, AMY-101 and pegcetacoplan
antagonize C3 activation, the IFX-1 monoclonal antibody inhibits C5a, and avdoralimab blocks the C5aR1 receptor.
Abbreviations: vWF: von Willebrand Factor, Ang2: Angiopoietin-2, C3aR: C3a receptor, C5aR1: C5a receptor 1, C5aR2:
C5a receptor 2, MASP1/2: Mannan-binding lectin serine proteases 1 and 2, ACE2: Angiotensin-converting enzyme 2,
TMPRSS2: Transmembrane protease, serine 2.
CREDIT: KELLIE HOLOSKI/SCIENCE IMMUNOLOGY
First release: 25 May 2021 immunology.sciencemag.org (Page numbers not final at time of first release) 4
Complement control for COVID-19
Markus Bosmann

Sci. Immunol. 6, eabj1014.

DOI: 10.1126/sciimmunol.abj1014

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